Therapies insulin

Patients on long-term insulin therapy are usually trained to administer their own medication. In order to safely use insulin, it is important to provide adequate (refrigerated) storage of the preparation, to maintain sterile syringes, to accurately measure the dose and fill the syringe, and to use a proper injection technique. Patients should rotate the sites of administration (abdomen, upper thighs, upper arms, back, and buttocks) to avoid local damage from repeated injection. 

Alternative routes for administering insulin are also being considered.51 In particular, a form of insulin (Exubera) has been developed that can be administered by inhalation or nasal spray, thus precluding the need for subcutaneous injection.88,104 Other modifications of the insulin molecule or use of chemical enhancers can increase the permeability of this hormone so that insulin can be administered through the skin (transcu-taneously) or even via oral or buccal routes.2,35 Technologic and practical advancements in insulin delivery continue to be explored, and methods for administering insulin may be safer and more convenient in the future. 

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Adjunct to diet to lower blood glucose in type 2 diabetes adjunct to insulin therapy in certain patients with type 1 diabetes... 

Type 2 diabetes adjunct to insulin therapy in the stabilization of certain cases of insulin-dependent diabetes (type 1)... 

Improving giycaemic control may not only reduce the rate of non-enzymatic glycosyiation and monosaccharide autooxidation, but lower polyol pathway activity. In addition, it should have a beneficial effect on other haemodynamic and hormonal factors involved in the development of diabetic vascular disease. However, in studies of diabetic retinopathy, rapid control of glucose levels by intensive insulin therapy has been shown to worsen vascular disease initially and it could be postulated that a sudden improvement in retinal blood flow promotes further free-radical damage as part of a reperfusion-ischaemic injury. 

Recommendations in this section may change based on results from the recent GLUCONTROL trial and the Volume Substitution and Insulin Therapy in Severe Sepsis Study. Both trials where stopped early due to lack of efficacy and safety concerns. 

Intensive insulin therapy, the administration of insulin three or more times daily to maintain preprandial blood glucose levels between 70 and 120 g/dL and postprandial blood glucose levels less than 180 g/dL, has been shown to decrease the incidence of proteinuria and albuminuria in patients with diabetes, both with and without documented nephropathy. The development and progression of nephropathy is also delayed in patients with type 1 DM receiving intensive insulin therapy. Continued benefits of intensive insulin therapy have been demonstrated up to 8 years after the study.16... 

Select appropriate insulin therapy based on onset, peak, and duration of action. 

Treatment of type 1 DM requires providing exogenous insulin to replace the endogenous loss of insulin from the non-functional pancreas. Ideal insulin therapy mimics normal insulin physiology. 

Currently, the most advanced form of insulin therapy is the insulin pump, also referred to as continuous subcutaneous insulin infusion (CSII). Using the short- or rapid-acting insulins only, these pumps are programmed to provide a slow release of small amounts of insulin as the basal portion of therapy, and then larger bolus doses are injected by the patient to account for the consumption of food. 

Thiazolidinediones may produce fluid retention and edema however, the mechanism by which this occurs is not completely understood. It is known that blood volume increases approximately 10% with these agents, resulting in approximately 6% of patients developing edema. Thus, these drugs are contraindicated in situations in which an increased fluid volume is detrimental, such as heart failure. Fluid retention appears to be dose-related and increases when combined with insulin therapy. 

Patient Encounter, Part 4 Oral to Insulin Therapy ... 

Several years have passed since you have been following MF s therapy. His weight is down to 230 lb (104.6 kg), and he tries to maintain his diet and exercise. His recent HbAlc levels have increased up to 8.4% from 7.2% despite combination therapy with sulfonylureas and metformin. The physician believes that it is time to start insulin therapy for MF and asks you to initiate therapy and follow his regimen. 

DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus Scientific review. IAMA 2003 289 2254-2264. 

Lifestyle modifications are always in order in patients who have developed or those who are at increased risk of developing NODAT.74 Insulin therapy and oral hypoglycemic agents are used often (Table 52-8) in patients in whom lifestyle modifications alone have not controlled blood glucose levels. See Chapter 40 for appropriate treatment regimens for diabetes. 

Van Den Berghe G, Wouters PJ, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001 345 1359-1367. 

Rollins C, Thomson C, Crane T. Pharmacotherapeutic issues. In Rolandelli RH, Bankhead R, Boullata JI, Compher CW, eds. Enteral and Tube Feeding. 4th ed. Philadelphia Elsevier 2005 291-305. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. New Engl J Med 2001 345 1359-1367. Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. New Engl J Med 1991 325 525-532. 

Octreotide -synthetic peptide analogue of somatostatin -abdominal pain, nausea, vomiting, diarrhea -local injection site reactions -cholelithiasis -sweating, flushing -hyperglycemia (many patients will require insulin therapy)... 

If a patient has inadequate control on two drugs, adding a third class can be considered (e.g., a glitazone, exenatide, a dipeptidyl peptidase-IV inhibitor, or basal insulin). Therapy should be guided by the A 1C, FPG, cost, additional benefits (e.g., weight loss), and avoidance of side effects). 

Goals for self-monitored blood glucose levels while on insulin therapy are a preprandial plasma glucose level between 80 and 110 mg/dL, and a 2-hour postprandial plasma glucose level less than 155 mg/dL. 

Put the following diagnostic tests in order of relevance for the management of a diabetic patient on insulin therapy, assigning 1 to the lest that should be recommended as first choice and 5 to the lest that should be recommended as a last choice. 

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